This story at a glance…

1. Drugmakers paid PBMs to prevent restrictions on opioid prescriptions.

2. These secret deals allowed opioids like OxyContin to flow freely, worsening the epidemic.

3. PBMs prioritized financial rebates over safety measures, delaying life-saving restrictions.

4. Internal documents reveal profit-driven decisions even as overdose deaths surged.

Drugmakers Paid PBMs to Avoid Opioid Restrictions

A recent investigation by The New York Times has revealed that opioid manufacturers, including Purdue Pharma, made secret payments to pharmacy benefit managers (PBMs) to prevent restrictions on opioid prescriptions. These deals allowed the continued widespread access to opioids, such as OxyContin, during the height of the opioid epidemic in the United States.

Pharmacy benefit managers, or PBMs, are powerful intermediaries in the prescription drug industry. They control which drugs are covered by insurance plans and negotiate rebates with pharmaceutical companies. The investigation shows that drugmakers paid large sums to PBMs to ensure opioids remained easily available to prescribers and patients, even as addiction and overdose deaths increased across the country.

How PBMs Influenced the Epidemic
PBMs, including Express Scripts, CVS Caremark, and Optum Rx, manage prescription benefits for over 200 million Americans. While these companies publicly claimed they were taking steps to curb opioid abuse, internal documents reveal a different picture.

For years, PBMs accepted large rebates from opioid manufacturers in exchange for allowing opioids to remain on preferred drug lists with minimal restrictions. This arrangement often discouraged insurers and employers from imposing safety measures like dosage limits or requiring doctors to provide additional justification for high-dose prescriptions.

Documents show that Purdue Pharma explicitly promoted a strategy to pay PBMs to avoid these safeguards. Internal emails and presentations described how the company offered rebates to eliminate "barriers to growth," enabling more prescriptions to flow without additional oversight.

The rebates formed a financial incentive for PBMs, insurers, and employers to maintain access to opioids, despite growing evidence of misuse and rising overdose deaths. For example, Purdue paid PBMs nearly $200 million annually in rebates by 2003, almost all for OxyContin.

Financial Gain Over Safety
As the opioid crisis worsened, PBMs’ contracts with manufacturers prioritized rebates over patient safety. Restrictions that could have slowed opioid overprescribing—like limits on pill quantities or stricter requirements for prescriptions—were often bargained away.

The documents reveal specific examples of these negotiations:

• In one case, Purdue and Merck-Medco convinced an insurer to abandon a planned limit of 60 OxyContin pills per month after presenting the financial loss from rebates.

• Mallinckrodt, another opioid manufacturer, described the rebate system as necessary to “remove barriers to growth.”

Even after the Centers for Disease Control and Prevention (CDC) issued stricter guidelines in 2016 to reduce opioid overprescribing, PBMs delayed implementing safeguards. Concerns over losing rebates from opioid manufacturers led some executives to postpone restrictions until 2018.

Late Efforts to Address the Crisis
By 2017, amid increasing public scrutiny and regulatory pressure, PBMs began introducing measures to restrict opioid access. These changes included dose limits, prior authorization requirements, and shifting patients toward less addictive alternatives. PBMs touted these steps as proof of their commitment to addressing the crisis.

However, internal communications suggest that these changes were often tied to financial negotiations. For instance, Purdue agreed to continue paying rebates to PBMs even after restrictions were introduced to ensure its drugs remained on approved lists.

Some PBM employees expressed frustration with the delays in implementing safeguards. In one email exchange, an Optum Rx executive called out the role of rebates in delaying action, citing the "countless deaths" caused by overprescription.

The Larger Impact
While drugmakers, distributors, and doctors have faced significant legal and financial consequences for their roles in the opioid epidemic, PBMs have largely avoided similar scrutiny until recently. The investigation sheds light on the influence these middlemen hold and how their financial priorities contributed to the opioid crisis.

By maintaining broad access to opioids in exchange for rebates, PBMs played a key role in the system that allowed overprescribing to persist for years.

Reflection
The opioid epidemic has been a heartbreaking crisis that has deeply impacted families and communities. The revelation of financial deals prioritizing profits over patient safety reminds us of the Apostle Paul’s words in 1 Timothy 6:10: “For the love of money is a root of all kinds of evil.” While financial gain is not evil in itself, placing profit above human lives reflects a broken system. This story challenges us to examine systems and structures in our society and advocate for accountability, justice, and compassion for those suffering from addiction. Let us pray for healing for individuals and families affected by this crisis and for wisdom for leaders working to prevent future harm.